Purpose
To describe the use of a lacrimal bypass tube in the management of epiphora in patients with epiphora attributable to lacrimal pump failure in facial palsy.
Design
Multicenter retrospective interventional study.
Methods
Information regarding patient demographics, diagnoses, symptoms, oculoplastic interventions, dacryocystorhinostomy, and Jones tube insertion were collected from patient charts.
Results
Eighteen patients were identified, in all of whom epiphora was clinically and/or radiologically assessed as being attributable to pump failure, lid laxity having been corrected. All had constant epiphora prior to Jones tube insertion. Dacryocystorhinostomy was performed in all; insertion of a Jones tube was performed simultaneously in 12, with delayed insertion in 6. Patients’ subjective epiphora improved postoperatively in 15 of 18 (83.3%) and at final median follow-up of 27.5 months (range, 6 months to 31 years); symptoms were improved in 13 of 18 (72.2%). Complications occurred in 13 of 18 (72.2%), including tube extrusion and the need for repositioning.
Conclusions
In this highly selected group of patients, Jones tube insertion led to symptom improvement in 83.3% postoperatively and in 72.2% at median follow-up of 27.5 months. Tube extrusion and migration were common, although such complications were not unexpected and were treatable.
The consequences of facial nerve paresis include exposure keratopathy, drooling, facial asymmetry, and paralysis of the ipsilateral muscles of facial expression. In addition, epiphora affects two-thirds of patients, is often multifactorial, and may be difficult to treat. Epiphora may be a result of reflex hypersecretion associated with ocular surface abnormalities, lid malpositions such as paralytic ectropion and lagophthalmos, failure of the normal lacrimal pump, and occasionally gustatory lacrimation, or a combination of these mechanisms.
After effective correction of upper and lower lid malpositions, some patients continue to suffer with epiphora. In these patients, continued paralysis of the ipsilateral orbicularis oculi muscle, an integral part of the normal lacrimal pumping mechanism, may be responsible for watering despite a patent nasolacrimal drainage system. Although the placement of a Jones lacrimal bypass tube has been previously described in such patients, to our knowledge there is no significant literature on the outcomes and complications of such interventions. We therefore conducted a multicenter retrospective study to characterize these parameters.
Methods
This was a 6-center retrospective interventional study of patients at the Royal Adelaide Hospital, Queen Victoria Hospital, Royal Victorian Eye & Ear Hospital, Vancouver Hospital, Royal North Shore Hospital, and Lions Eye Institute. Patients were identified from the institutions’ respective databases. Inclusion criteria were: facial palsy, patency of drainage system demonstrated on clinical testing and/or imaging prior to insertion of Jones tube, previous eyelid surgery (if required) to correct malposition of the punctum and address lid laxity, epiphora assessed (clinically, with or without lacrimal scintigraphy and dacryocystography) as secondary to pump failure, and insertion of a Jones lacrimal bypass tube. The only exclusion criterion was an alternative explanation (other than pump failure) for epiphora, for example, gustatory lacrimation, exposure keratopathy, lacrimal drainage apparatus stenosis/obstruction (assessed clinically or radiologically), or uncorrected lid malposition. As this was a retrospective clinical study, the diagnosis of pump failure was a clinical diagnosis of exclusion in each case. Main outcome measures were: resolution of epiphora (subjective judgment by the individual patient), functional tests of lacrimal drainage (patency to syringing and functional endoscopic dye tests, depending on the individual surgeon and case), and complications of surgery.
Two broad categories of patients with epiphora were included in the study: 1) those with previous, freely patent dacryocystorhinostomies (DCR), who then underwent Jones tube insertion; and 2) patients with no previous lacrimal surgery, in whom the nasolacrimal system was patent to syringing, who then underwent simultaneous DCR and Jones tube insertion.
Results
Demographics
Eighteen patients were identified, of whom 9 were female (50.0%). The right side of the face was affected in 10 cases (55.5%). The median age at diagnosis of facial palsy was 60 years (range, 0 to 75), with the most common etiology being the result of excision of tumors (acoustic neuroma excision and parotidectomy); a full list of etiologies is found in Table 1 . The median time from diagnosis of facial palsy to first intervention for epiphora was 12 months (range, 2 months to 31 years). All patients underwent one or more eyelid procedures (excluding nasolacrimal system surgery) for epiphora (range, 1 to 5 procedures; Table 2 ); lid tightening was performed in 15 of 18 cases (83.3%).
| Cause | No. of Patients |
|---|---|
| As a result of excision of malignancy | 4 |
| As a result of excision of acoustic neuroma | 4 |
| Nonresolving Bell palsy | 3 |
| Traumatic | 2 |
| Congenital | 1 |
| Perineural invasion by squamous cell carcinoma | 1 |
| Postmastoidectomy | 1 |
| Infectious disease (poliomyelitis, leprosy) | 2 |
| Procedure | Number of Patients |
|---|---|
| Medial canthoplasty/medial tarsorrhaphy | 9 |
| Medial canthal resection/shortening/repair/plication | 5 |
| Lateral tarsal strip | 10 |
| Other lid tightening (including fascia lata sling) | 3 |
| Upper eyelid weight insertion | 9 |
| Lateral tarsorrhaphy/canthoplasty | 9 |
| Lower lid elevation with sclera graft | 2 |
| Botulinum toxin to lacrimal gland | 3 |
Dacryocystorhinostomy
A brief outline of the patients’ characteristics is shown in Table 3 . At a median of 3 years after diagnosis of a facial palsy (range, 6 months to 51 years), all patients underwent DCR, which was performed simultaneously with insertion of a lacrimal bypass tube in 12 cases; in 6 cases, DCR was performed separately at a median 8.5 months (range, 6 to 60 months) prior to tube insertion. DCR was performed externally in 10 of 18 cases (55.5%) and endoscopically in 8 (44.4%). Prior to DCR, the nasolacrimal system was patent to syringing in 15 of 16 cases (93.75%), with some reflux noted in 2 of these cases, consistent with stenosis (no records for 2 patients, who underwent secondary Jones tube insertion for ongoing epiphora after previously anatomically successful DCR). Of the 6 patients who did not have Jones tube insertion simultaneously with DCR, a partial improvement in epiphora was noted in 2 (33.3%), one of whom had been obstructed to syringing prior to DCR; however, epiphora still remained a constant problem.
| No. | Age/Gender (years, M/F) | Primary or Secondary Insertion of Jones Tube | External or Endonasal DCR | Scintigraphy Pre Jones Tube Insertion | Initial Outcome Following Jones Tube Insertion | Complications | Final Outcome at End of Study | Tube Still In Situ? (Y/N) | Follow-up: Months |
|---|---|---|---|---|---|---|---|---|---|
| 1 | 51/F | Primary | External | Not done | Improved | Extrusion | Improved | Y | 72 |
| 2 | 73/M | Primary | External | Not done | Improved | Extrusion | Epiphora | N | 6 |
| 3 | 66/M | Primary | External | Not done | Improved | Extrusion | Improved | Y | 65 |
| 4 | 72/M | Primary | External | Not done | Improved | Nil | Improved | Y | 22 |
| 5 | 50/F | Secondary | External | Not done | Improved | Nil | Improved | Y | 6 |
| 6 | 70/F | Secondary | External | Not done | Improved | Extrusion a | Epiphora | N | 372 |
| 7 | 54/F | Secondary | External | Not done | Improved | Conjunctival overgrowth, extrusion | Improved | Y | 120 |
| 8 | 65/M | Secondary | Endonasal | Presac delay | No improvement | Needed repositioning | Improved | Y | 60 |
| 9 | 53/F | Primary | Endonasal | Presac delay | Improved | Nil | Improved | Y | 27 |
| 10 | 78/F | Secondary | External | Presac delay | Improved | Extrusion | Improved | Y | 19 |
| 11 | 66/F | Primary | External | Presac delay | Improved | Nil | Improved | Y | 15 |
| 12 | 35/F | Primary | Endonasal | Presac delay | No improvement | Needed repositioning | Epiphora | Y | 29 |
| 13 | 60/M | Primary | Endonasal | Presac delay | No improvement | Needed repositioning | Epiphora | Y | 17 |
| 14 | 73/M | Primary | Endonasal | Presac delay | Improved | Conjunctival overgrowth | Improved | Y | 120 |
| 15 | 65/M | Primary | Endonasal | Presac delay | Improved | Needed repositioning | Improved | Y | 24 |
| 16 | 6/M | Primary | Endonasal | Not done | Improved | Extrusion, needed repositioning | Improved | Y | 120 |
| 17 | 8/M | Primary | Endonasal | Not done | Improved | Extrusion | Epiphora | N | 12 |
| 18 | 65/F | Secondary | External | Not done | Improved | Nil | Improved | Y | 28 |
a After initial extrusion at 6 weeks, this patient had a longer tube inserted, which also extruded; this was replaced with a medial canthoplasty before developing a fistula and pyogenic granuloma, which required excision.
Symptoms Prior to Jones Tube Insertion
Prior to Jones tube insertion or DCR plus Jones tube insertion, all patients had constant epiphora. Exacerbating factors were present in 6 patients, including reading, posture, and cold weather. In 16 patients where a fluorescein dye disappearance test (FDDT) was performed prior to tube insertion, all (16/16) had delayed clearance of dye. Fifteen of 17 patients were noted to have lagophthalmos, which varied from 1 to 5 mm (median 2 mm). Dacryoscintigraphy was performed in 8 of 16 patients (50.0%) and showed a pre-sac delay in all. Three patients were noted to have dry eye symptoms prior to DCR and simultaneous Jones tube insertion, which was associated with lagophthalmos of 2 to 3 mm in each case and medial canthal tendon laxity in 2; all experienced an improvement in epiphora following Jones tube insertion without exacerbation of their dry eye symptoms.
Jones Tube Insertion
A plain Jones tube was inserted in 17 of 17 cases, with a fixation hole in 2 of these cases; in 1 case, the original type of Jones tube was not clear from the chart. These tubes were inserted between the lid margin and caruncle in 14 of 18 cases (77.8%) and were transcaruncular in 3 (16.7%) (no data, 1 case). No complications at the time of surgery were noted.
Initial Outcome After Tube Insertion
With a lacrimal bypass tube in situ, symptoms were initially improved in 15 of 18 cases (83.3%), being described as intermittent/provocative in 3 of these 15 cases. In 3 cases, there was no improvement in epiphora. A postoperative FDDT was noted to be improved in 11 of 11 cases; however, a delay relative to the other side was seen in 5, 3 of whom had no improvement in epiphora. Seven patients had a postoperative functional endoscopic dye test, which revealed the flow of fluorescein into the nose in all 7, albeit weakly in the 3 patients with no improvement in their symptoms; in 1 of these patients, medial migration of the tube, abutting the septum, was noted.
The 3 patients with no initial postoperative improvement in symptoms were a 60-year-old man, 65-year-old man, and 35-year-old woman, respectively, with differing etiologies (nonresolving Bell palsy, parotidectomy, and acoustic neuroma); however, the latter 2 had their facial nerve sacrificed as part of tumor excision. All had undergone aggressive management of lid malpositions with 1 mm, 2 mm, and 0 mm of lagophthalmos preoperatively. All underwent endoscopic DCR, with simultaneous insertion of Jones tube in the female patient; site of insertion was between caruncle and lower lid in all cases. After tube repositioning in the second case, a 50% improvement in symptoms was noted; however, tube repositioning led to no improvement in the first.
Complications of Placement of Lacrimal Bypass Tubes
Complications occurred in 12 of 18 cases (66.7%), with no complications in the remaining 6. Extrusion occurred in 8, with 1 case having multiple extrusions. Five cases required repositioning of the tube, with 1 patient undergoing 4 repositioning procedures. Excision of an excess conjunctival fold was required in 2 cases. After initial extrusion at 6 weeks, 1 patient had a longer tube inserted, which also extruded; this was replaced with a medial canthoplasty before developing a fistula and pyogenic granuloma, which required excision, and the patient has ongoing epiphora (no tube in situ).
Of the 12 patients who underwent primary Jones tube insertion at the time of DCR, the tube extruded in 5 (41.7%) and tube repositioning was needed in 4 (33.3%). Of the 6 patients who underwent secondary tube insertion, 3 of 6 (50%) extruded and 1 (16.7%) required a repositioning procedure.
Final Outcomes
At a median 27.5 months’ follow-up (range, 6 months to 31 years), symptoms were improved in 13 of 18 cases (72.2%), with ongoing symptoms in 5 patients, of whom a tube was not in situ in 3; the symptoms of all of these 3 had been previously relieved by tube placement. In 1 of these 3, tube replacement was awaited and in the other 2, the tube was not replaced (patient choice because of malignancy in 1, complications after Jones tube insertion in the other, described previously). Of the 13 with improvement, symptoms were absent in 5, described as improved in 4, and intermittent/provocative only in 4.
Comparison of Outcomes for Primary and Secondary Placement of Tubes
Of the 12 patients undergoing primary placement of a Jones tube, initial symptom improvement was found in 10 of 12 cases (83.3%), with 8 of 12 (66.7%) having improved symptoms by the end of the study. Of the 6 patients undergoing secondary tube placement, 5 of 6 (83.3%) experienced initial improvement in symptoms, with the same number having improved symptoms by the end of the study.
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